Referral Guidelines - Children and Young Adult - Smjernice za odabir rendgenskih snimki u dentalnoj medicini

Referral Guidelines for Appropriate Use of X-Ray Imaging in Dentistry

Referral Guidelines for Imaging of Children and Young Adults

CLINICAL TASK	INVESTIGATION	DOSE	RECOMMENDATION	COMMENTS
Caries diagnosis: initial visit	Initial clinical examination – intraoral posterior bitewing radiographs		Indicated	Posterior bitewing radiographs are an essential adjunct to clinical examination. The initial clinical examination must include an assessment of caries risk (as high, medium or low). The assessment of risk is relevant in determining when to take radiographs and therefore must be carried out at each subsequent recall examination ensuring that the time interval for radiography becomes patient-specific. It is feasible that adoption of the following recommendation may lead to more radiographs being taken (IAEA).
	Intraoral bitewing radiographs		Indicated	For high and moderate caries risk patients, there is a significant addition to diagnostic yield of clinical examination alone. For low caries risk patients, there is less strong evidence. Where a child is classified as high caries risk the subsequent bitewing examination should be after 6 months intervals between subsequent bitewing radiographic examinations must be reassessed for each new period, as individuals can move in and out of caries risk categories with time (IAEA).
	Fibreoptic transillumination (FOT)	None	Indicated	Useful adjunct to radiography for detection of aproximal lesions (IAEA).
	Laser fluorescence methods Infrared Laser Fluorescence (DIAGNOdent)	None	Specialised investigation	Adjunct to radiography, but with significant false positive rates (IAEA).
	Electrical Conductance Measurement (ECM)
	Quantitative Light-induced Fluorescence (QLF)
	Digital Imaging Fiber Optic Transillumination (DIFOTI)			Alternative methods to using ionising radiation in caries diagnosis should be considered once their diagnostic validity has been clearly established (IAEA).
Caries diagnosis: monitoring	Clinical examination	None	Indicated	Clinical examination of dried tooth surfaces with good lighting is essential at all stages of monitoring and review in caries detection (IAEA).
Caries diagnosis: monitoring	Intraoral bitewing radiographs		Indicated	Intervals between radiographic examinations dependent upon clinically assessed caries risk status. Ø Moderate caries risk children: the subsequent bitewing examination should be after 12 months. Evidence of no new or active lesions would be an indicator that the child had entered the low risk category. Ø Low caries risk children: the subsequent bitewing examination should be after 12-18 months in the deciduous dentition and 24 months in the permanent dentition. More extended recall intervals may be employed if there is explicit evidence of continuing low caries risk (IAEA).

Table 1.1: Caries Risk Factors RP136

Endodontic treatment IAEA i RP172

CLINICAL TASK	INVESTIGATION	DOSE	RECOMMENDATION	COMMENTS
Endodontic therapy: working length estimation	Intraoral periapical radiograph		Indicated	More than one radiograph may be needed in multi-rooted teeth to avoid superimpositions and allow parallax localisation of roots and canals.
	Electronic apex locator	None	Indicated	Normally need confirmation of measurement by radiography, although some guidelines suggest that apex locators may be used alone in selected cases when the operator has confidence in the reading.
	CBCT	to	Indicated only in specific circumstances	If high resolution CBCT is already available, then this may allow measurement of working length, but CBCT should not be used as the normal method of working length estimation.
Endodontic therapy: Mid-fill (“Master point”)	Intraoral periapical radiograph		Indicated	Radiograph of tooth with master gutta percha cone in position may be indicated, depending on clinical judgement.
Endodontic therapy: end of treatment	Intraoral periapical radiograph		Indicated	End of treatment radiograph needed for confirmation of adequate obturation and as a baseline for future image comparison.
Endodontic therapy: review	Intraoral periapical radiograph		Indicated	Recommendations on timing of review radiography is inconsistent between guidelines and lacks an evidence base. A review at 12 months after treatment completion has some evidence to support it. Review after this point depends on clinical judgement.

Trauma

CLINICAL TASK	INVESTIGATION	DOSE	RECOMMENDATION	COMMENTS
Trauma (teeth and alveolar bone) (IAEA i RP172)	Intraoral periapical radiograph		Indicated	Combinations of intraoral radiographs using different perspectives provide fine detail and are usually sufficient for dental trauma.
	Intraoral occlusal radiograph		Indicated
	Panoramic radiograph		Indicated	Provide more extensive coverage of bone for suspected dento-alveolar fracture.
	CBCT	to	Indicated only in specific circumstances	Localised high resolution CBCT appears to have higher diagnostic accuracy for root fracture detection, but is indicated only when conventional radiographs have proved to be inadequate for patient management. High level of patient cooperation is needed, as movement artefact will reduce fracture detection.
Trauma (maxillofacial)	Panoramic radiograph		Indicated	Combinations of panoramic and facial bone radiographs are the traditional methods of detecting bone injuries. CBCT and MDCT are increasingly replacing these.
	Facial/skull radiographs		Indicated
	CBCT	to	Indicated
	MDCT	to	Indicated

Internal derangement of the temporomandibular joint (IAEA)

CLINICAL TASK	INVESTIGATION	DOSE	RECOMMENDATION	COMMENTS
Internal derangement of the temporomandibular joint	Clinical examination	None	Indicated	Usually provides the information required for diagnosis
	CBCT	to	Indicated only in specific circumstances	In cases where there is uncertainty about the origin of the symptoms, e.g. potentially juvenile rheumatoid arthritis
	MR	None	Indicated only in specific circumstances	In cases where there is uncertainty about the origin of the symptoms, e.g. potentially juvenile rheumatoid arthritis